Shoulder External Impingement

Normal Anatomy
The shoulder has a lot
of soft tissue within a
small amount of space
Also a very mobile joint
with lots of movement
These 2 components
increase the changes of
pinching during
movement
 Shoulder Impingement
These disparate findings are believed to be at least in part
due to the fact that mechanical impingement is probably a
physical condition rather than a clearly identifiable
diagnostic entity.

(Kibler et al., 2013)

It is increasingly advocated that this diagnosis is no more

specific than a diagnosis of anterior or posterior shoulder
pain, and no more effective in directing treatment

(Kibler et al., 2013; Schellingerhout et al., 2008)

 Shoulder Impingement
External (Bursal Sided)
Impingement Internal (Articular) Impingement
Classic Subacromial Pinching of the rotator cuff
Impingement between between humeral head and
humeral head and acromion posterior superior glenoid
or coracoacromial ligament
Shoulder Impingement
 External Impingement
Impingement of rotator
cuff underneath acromion
OR coracoaromial
arch/ligament
Impingement is NORMAL
due to the small space
available
Pathology occurs due to
Overuse
Trauma
Alignment or Anatomy
Soft Tissue Imbalances
 Impingement Stages
Stage 1 Stage 2 Stage 3
< 25 years old 25 -40 years 40+ years
Acute Progression from Mechanical
disruption of
inflammation acute oedema and
tendons (tear)
and oedema haemorrhage to
Osteophytes
and fibrosis and
under acromion
haemorrhage tendinitis of the
Thickening of
in the rotator rotator cuff
coracoacromial
cuff Usually responds arch
Reversible and to conservative More likely to
Non operative management require surgery

(Neer, 1983)
 Impingement Causes
Primary Secondary
Result of a direct compression of Secondary to another syndrome
the rotator cuff tendons between which causes humeral head
humeral head and overlying
migration
anterior third of the
acromion/coracoacromial arch/ Rotator Cuff weakness
ligament Glenohumeral instability
Change in anatomy of
Scapular Dyskinesia
acromion
Acromioclavicular arthrosis Posterior Capsule tightness
Coracoacromial ligament Neurological paralysis
hypertrophy
(Chang, 2004)
Subacromial bursa thickening
or fibrosis
Trauma
Repeated Overhead activity
 Subacromial Vs Coracoacromial
Impingement of the rotator
cuff tendon can occur
against anterior aspect of
the acromion OR the
coracoacromial arch
Coracoacromial
impingement has more pain
into horizontal adduction
There is very subtle
differences in presentation
which will affect
management
External Impingement- Assessment
Subjective History
History of instability
History of impingement
Job or sport that requires
repeated overhead activity
Subjective Symptoms
Insidious Onset
Pain anteriorly, superiorly
and laterally in shoulder
Pain in positions of flexion
and internal rotation
(Sometimes horizontal
adduction)
External Impingement- Assessment
Objective
Painful arc
Pain resisted lateral
rotation
Hawkins Kennedy
Neers
Global Assessment
Cervical
Scapula
Thoracic
 Management
Remember impingement is NORMAL and only
pathological due to the following
Overuse
Trauma
Alignment or Anatomy
Soft Tissue Imbalances
Treatment is used to modify the above
Anatomy cannot be changed, therefore
surgery required
 Management

Soft Tissue Imbalances

Management- Soft Tissue Imbalances
Rotator Cuff pull humeral head into glenoid
Should pull centrally
Muscle Imbalance can change the position of
the humeral head within the glenoid
Main imbalances
Big V Small (Deltoid V Rotator Cuff)
Posterior V Anterior (Subscapularis V Posterior
Cuff)
 Deltoid V Rotator Cuff
Deltoid pulls humeral
head superior
If rotator cuff are
dysfunctional the net
force of deltoid is
increased
Humeral head migrates
superiorly during
elevation
Causing impingement
 Deltoid V Rotator Cuff
Pain free range exists
because as elevation
continues the pull of
the deltoid changes
Less superior pull is
produced as elevation
increases
Pain at very end of
range simply due to
space available
 Posterior Cuff V Subscapularis
If subscapularis is
dominant the humeral
head will migrate
anteriorly
Increasing risk of
humeral head impinging
against coracoacromial
arch and acromion
 Posterior Cuff
It therefore stands to
reason that
rehabilitation of the
posterior cuff will be
beneficial
But what exercises are
most effective for the
posterior cuff?
 Rationale For Exercises
A review paper in 2009 by
Mike Reinold looked
various EMG studies of
shoulder muscles
Concluded the 3 best
exercises for posterior
cuff were
Side Lying ER
Prone ER at 90 Abduction
ER with Towel (30
Abduction)
(Reinold et al., 2009)
 Management- Soft Tissue Imbalances
Posterior capsule
tightness can alter
shoulder
arthrokinematics
Tightness in the Posterior
Capsule and Posterior
Band of the inferior
capsule reduce superior
head migration

(Muraki et al., 2010; Tyler et

al., 2000)
 Management- Soft Tissue Imbalances
Manual Therapy to soft
tissue can improve pain,
range of movement,
function and strength
Joint mobs, Soft tissue
release, etc etc

(Bang & Deyle, 2000;

Senbursa et al., 2007; Teys
et al., 2008)
 Management- Soft Tissue Imbalances
HEP
Horizontal adduction
Sleeper Stretch (Is this
similar to Hawkins
Kennedy?)
Management

Alignment
 Management- Alignment
Any deviation of the
scapula will affect
shoulder kinematics
Points of impingement
are coracoacromial
ligament, or acromion
Both parts of scapula
 Management- Alignment
Read the following paper
for an in depth look at the
biomechanics associated
with shoulder
impingement syndrome

Ludewig PM, Braman JP.

Shoulder impingement:
biomechanical
considerations in
rehabilitation. Man Ther
2011; 16(1): 33-9.
 Management- Alignment
Restricted thoracic Scapula Dyskinesis
extension with Reduced scapular
elevation upward rotation
Increased thoracic Increased internal
kyphosis (try elevated rotation (Medial Border
Winging)
the arms while sitting
Increased anterior tilt
slumped)

(Seitz et al., 2011) (Cools et al., 2003)

(Bullock et al., 2005)
 Management- Alignment
Increase thoracic extension Increase scapular upward
and rotation rotation, posterior tilt and
Thoracic mobilisation and external rotation
manipulation Serratus anterior and Lower
Trapezius Rehab

(Boyles et al., 2009) (Cools et al., 2003; Ludewig

& Cook, 2000; Ludewig &
Reynolds, 2009; Ellenbecker
& Cools, 2010; Roy et al.,
2009; Hung et al., 2010;
Cools et al., 2013; Dickens
et al., 2005)
 Rationale For Exercises

Serratus Anterior
Push up Plus
Dynamic Hug
Serratus Punch 120
Wall Slides
Lower Trapezius
Prone Full Can
Prone ER at 90 Abduction
Bilateral ER (Shoulder Ws)
(Reinold et al., 2009)
 Subacromial V Coracoacromial
Subacromial Coracoacromial
Avoid Flexion Avoid Horizontal Adduction
 Management
Mobility BEFORE Stability Stability
Mobility Posterior Rotator Cuff
Soft tissue release/MET Serratus Anterior
Pec Minor Lower Trapezius
Upper Trapezius
Subscapularis Stability Principles
Rhomboids
Levator Scapulae
1. Motor Control
Joint Mobs 2. Isolated Strengthening
Posterior and Inferior 3. Endurance
Capsule
Scapular Upward
4. Neuromuscular Control
Rotation 5. Functional/ Sport Specific
 References
Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy
for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000; 30(3): 126-37.
Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust
manipulation on patients with shoulder impingement syndrome. Man Ther 2009; 14(4): 375-80.
Bullock MP, Foster NE, Wright CC. Shoulder impingement: the effect of sitting posture on shoulder
pain and range of motion. Man Ther 2005; 10(1): 28-37.
Chang WK. Shoulder impingement syndrome. Phys Med Rehabil Clin N Am 2004; 15(2): 493-510.
Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitation of scapular
dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med 2013.
Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. Scapular muscle recruitment
patterns: trapezius muscle latency with and without impingement symptoms. Am J Sports Med
2003; 31(4): 542-9.
Dickens VA, Williams JL, Bhamra MS. Role of physiotherapy in the treatment of subacromial
impingement syndrome: a prospective study. Physiotherapy 2005; 91(3): 159-64.
 References
Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries:
an evidence-based review. Br J Sports Med 2010; 44(5): 319-27.
Ho CY, Sole G, Munn J. The effectiveness of manual therapy in the management of musculoskeletal
disorders of the shoulder: a systematic review. Man Ther 2009; 14(5): 463-74.
Hung CJ, Jan MH, Lin YF, Wang TQ, Lin JJ. Scapular kinematics and impairment features for
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Ludewig PM, Braman JP. Shoulder impingement: biomechanical considerations in rehabilitation.
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Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people
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pathologies. J Orthop Sports Phys Ther 2009; 39(2): 90-104.
Muraki T, Yamamoto N, Zhao KD, et al. Effect of posteroinferior capsule tightness on contact
pressure and area beneath the coracoacromial arch during pitching motion. Am J Sports Med 2010;
38(3): 600-7.

 References
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